Re: US-POLITICS - Qualified Provider Language Passed by Congress

Re: US-POLITICS - Qualified Provider Language Passed by Congress

Martha Rinker

12/19/2000

It is a major legislative victory for the O&P field! As a result of the
efforts of O&P field and the governemnt relations staff that support the
field, Congress passed the Medicare Givebacks bill on Friday as a part of
the omnibus budget bill known as the Consolidated Appropriations Act,
2001. The president is expected to sign the bill this week.

The language includes:
· A full update for O&P of 3.7 percent - That is the 1 percent O&P was
scheduled to receive under the BBA plus an additional 2.7 percent which will
give O&P the full 3.7 percent that reflects the 2000 final quarter Consumer
Price Index-Urban (CPI-U) increase. (Note: the effective date of the
additional 2.7 percent would go into effect on July 1, 2001.)

· The qualified provider language - Limits access to prosthetic and
custom fabricated orthotic Medicare payments to qualified practitioners
(ABC, BOC, and qualified PTs and OTs) and/or qualified suppliers (ABC and
BOC accredited facilities).

· A 96-1 study - The Comptroller General is required to report to
Congress on the impact of HCFA's Ruling 96-1 and the effect on Medicare and
Medicaid payments if that ruling were overturned.

· Replacement of Prosthetic Devices and Parts - Reduces the five-year
restriction on the replacement of prosthetic devices and parts to three
years or less with medical necessity documentation.

· Medicare Appeals - The Medicare appeals process has been modified.
HCFA has been mandated to make initial determinations within 45-days of
receiving the claim for benefits, redetermination within 30 days of the
beneficiary or provider's request and an appeals process for
reconsideration.

· New Technologies - HCFA is required to establish procedures that
permit public consultation for coding and payment determinations for new
diagnostics tests and devices. They are also required to report to Congress
on specific procedures used to adjust payments for advanced technologies.

The Qualified Provider proposal has a long history. A special report in the
January 2001 Almanac will give you a complete picture of the work AOPA has
done on this issue for the past four years. In order to set the record
straight and give the ListServ participants an understanding of the issue,
here is an abridged history:

This effort has been guided and conducted under the direction of the AOPA
leadership past and present. The majority of the O&P education members of
Congress have received has been by AOPA members in their facilities and
through their participation in the AOPA Policy Forums.

Even though AOPA members knew there were problems of unqualified providers
billing Medicare for O&P devices in the field, we needed data to prove it.
We had to be able to show Congress that a problem existed. It cost Medicare
part of its budget and it harmed Medicare beneficiaries, and there was a
legislative solution.

The data became available in 1997 from the Health and Human Services (HHS)
Office of the Inspector General (OIG) and from the Health Care Financing
Administration (HCFA).

In 1997, the OIG released its report, Medicare Orthotics (OEI-02-95-00380).
The OIG estimated that Medicare could save $8 million a year for the 20
orthotic L codes that were the basis of the study, if it considered
stricter standards for who is allowed to bill for orthotics, such as
requiring professional credentials for orthotic suppliers.

Also in 1997, AOPA gained access to HCFA's 1996 and 1997 payment data, which
listed who Medicare paid for each individual O&P L code. The payment data
showed that suppliers without the necessary skills and facilities are
providing many highly technical custom O&P services. For example,
department stores were reimbursed for artificial legs, DME supply companies
were paid for custom wrist orthoses and pharmacies were receiving payments
for leg braces.

Using the HCFA data, AOPA estimated that Medicare could save well over $20
million a year, or at least $100 million over five years, if O&P care now
being billed under custom L codes was provided only by truly qualified
professionals.

Using the OIG reports and the HCFA payment data, we were able to show
members of Congress that a problem did exist. We were also able to show that
legislation was necessary to assure that Medicare beneficiaries were getting
quality care and that taxpayers were getting what they paid for with their
tax dollars.

In July 1999, Senator Tom Harkin (D-IA) continued his efforts on behalf of
the O&P field when he introduced his Medicare Waste Tax Reduction Act of
1999 (S. 1451). Included in this proposal to improve efforts to combat
Medicare waste, fraud and abuse was Section 20 with language to limit access
to the custom L codes to qualified providers. This language drafted by the
Senate Legislative Counsel and approved by HCFA.

Congress is not in the business of licensing professions, nor will it define
qualifications of professionals that is why the legislative proposal is
silent on specific educational standards. It only has jurisdiction over
federal programs. Licensure is a state activity. It was in consultation
with the Senate Legislative Counsel that the approach to limiting the access
to custom L codes was determined.

A number of provider groups were not happy with this qualified provider
proposal including occupational therapists (OTs) and physical therapists
(PTs). Even though the original language would have included them under
their Medicare scope of practice, they requested specific language to
include OTs and PTs. The political reality, as those of you who have worked
on state licensure legislation know, both groups have many individual
members who are active on a grassroots level and political action committees
(PACs). In order to keep the proposal moving it was changed to reflect the
OT and PT Medicare scope of practice for some orthotic devices. In
addition, members of Congress who represent rural districts were concerned
about access to care issues - are there enough O&P professionals to provide
all the O&P care that is requires. It was the decision of the AOPA
leadership that a step toward changing the Medicare reimbursement system for
custom O&P was better than what we have now where no one is served.

Both Senate and House liked the proposal. It made sense for beneficiary
care, and it saved money. There were promises to include it in any Medicare
proposal they drafted. The chairman of the House Ways and Means Health
Subcommittee was enthusiastic about our proposal but asked us to work out
some differences with the National Orthotics Manufacturers Association
(NOMA). A NOMA member is one of his constituents, as are a few AOPA
members.

During the negotiations with the House, Senate Democrats introduced their
version of a Medicare givebacks bill. They included the original Sec. 20
from Harkin's S. 1451, but added BOC to the list of qualified providers. One
of the original co-sponsors of that Democratic Medicare Givebacks bill, a
senator from Maryland, included BOC in the list at the behest of her
constituents. The addition of BOC was then added to the House version of the
bill for uniformity and increased chances of passage.

The final qualified provider legislative language also includes a
negotiated rulemaking requirement. This means that all the qualified
providers parties must meet with HCFA to negotiate who is qualified to
provide each code and the list custom L codes that will be limited to those
qualified disciplines. In other words, the affected parties will negotiate
the rules for the reimbursement policy. This gives all the qualified
providers a chance to present their qualifications and make their best case
for their ability to provide each custom L code.